DOES FECAL DIVERSION INDUCE A CLINICAL RESPONSE TO CROHNS DISEASE OF THE COLORECTUM?
Amy L. Lightner*1, Hassan Buhulaigah2, Karen Zaghiyan2, Prashansha Vaidya1, Miguel D. Regueiro1, Phillip Fleshner2
1Cleveland Clinic, Cleveland, OH; 2Cedars Sinai, Los Angeles, CA
Background: Fecal diversion is now selectively used in cases of medically refractory Crohn's proctocolitis or advanced perianal disease. The aim of this study was to evaluate the rate of, and clinical factors, associated with clinical response following fecal diversion in CD.
Methods: A retrospective chart review of adult CD patients undergoing an ileostomy for medically refractory distal disease (proctocolitis, perianal disease, segmental colitis, proctitis) between 2000-2019 at two inflammatory bowel disease centers was conducted. The primary outcome was the rate of clinical response defined as improvement in urgency, abdominal and perineal pain, decreased anal fistula drainage or weight gain. The secondary outcome was to assess factors associated with clinical response to fecal diversion.
Results: The study cohort of 98 patients had a median age of 40 (range, 19-84) years and included 50 females (51%). Median duration of disease was 15 (1-43) years. Indication for surgery was medically refractory proctocolitis and perianal disease (n=48;49%), perianal disease alone (n=34;35%), proctocolitis (n=8;8%), segmental colitis (n=5;5%), and proctitis alone (n=3; 3%). Medications used before surgery included corticosteroids (n=43;44%), immunomodulators (n=33;34%) and biologics (n=52;53%). Biologics used included adalimumab (n=21), infliximab (n=10, certolizumab (n=8), vedolizumab (n=8) and ustekinumab (n=5). Only 16 (17%) patients were active smokers. Following ileostomy formation, 32 (33%) patients had a clinical response. The association between patient features and clinical response is shown in Table 1. Clinical response to fecal diversion was significantly decreased in the setting of proctocolitis with perianal disease (p=0.005) and pre-diversion exposure to biologics (p=0.04).
Conclusions: This largest report in the biologic era of fecal diversion for medically refractory CD proctocolitis or perianal disease showed that only 33% of patients achieved a clinical response. Biologic use before fecal diversion and diversion for proctocolitis with perianal disease was associated with a significantly lower clinical response suggesting that the worse the disease, the lower the chance of response.
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